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Presacral venous plexus bleeding in patients with pelvic fractures. Bleeding stoppage methods.

Darja Ivanova

Faculty of Medicine, IV

November 22, 2016

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The sacrum and innominate bones along with many ligamentous complexes, comprise the pelvis. Fractures and ligamentous disruptions of the pelvis suggest that major forces were applied to the patient. (1) auto-pedestrian crashesmotor vehicle crashesmotorcycle crashesa fall from a height greater than 3.6 meters (1)

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Disruption of the pelvic ring tears the pelvic venous plexus and occasionally disrupts the internal iliac arterial system. (2)

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1. AP compression,

2. lateral compression,

3. vertical shear,

4. complex (combination) pattern (2)

Patterns of force leading to pelvic fractures

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Patients with hemorrhagic shock and unstable pelvic fractures have four potential sources of blood loss:

1.fractured bone surfaces,

2.pelvic venous plexus,

3.pelvic arterial injury,

4.extrapelvic sources. (1)

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Plexus venosus presacralis

https://www.researchgate.net/figure/40025768_fig11_Fig-11-Presacral-space-Courtesy-of-Robert-

Werkmeister-Dallas-TX-with-permission (5)

(6)

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Damage control management in the polytrauma patient

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Damage Control Part 0: Rapid Transport to Definitive Care

Damage Control Part 1: Rapid Control of Hemorrhage and Contamination

Damage Control Part 2: Resuscitation Damage Control Part 3: Return for Completion of

Operative Repairs Damage Control Part 4: Definitive Abdominal Closure

(4)

Damage control

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1. Early decision making» hypotension

» elevated lactate and/or base deficit

2. Triad of death

3. Associated injuries

4. Predicted or present abdominal compartment syndrome

5. Planned reoperation (4)

Indications

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1. Hypothermia T < 34°C, (4)

100% mortality T <32.8°C (3)Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: the new face of damage control. J Trauma-

Inj Infect Crit Care. 2010;69(4):976–90

2. Coagulopathy »decreased circulating concentration

»dysfunction of various components of the clotting mechanism – activation of protein C,– depletion of I, II, V, VII, VIII, IX and X clotting factors

3. Acidosis pH < 7.2 (or base excess greater than 8 in a patient with a corrected pH due to hyperventilation) (4)

Triad of death

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1. Early decision making

2. Triad of death

3. Associated injuries

4. Predicted or present abdominal compartment syndrome (ACS)

5. Planned reoperation (4)

Indications

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The main components include: Permissive hypotension and restrictive fluid administrationHaemostatic resuscitationRewarmingCorrection of acidosisArrest of haemorrhage by surgical and non-surgical techniques (3)

Damage control resuscitation (DCR)

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pelvic bindersapplication of compressive dressings to actively

bleeding wounds the use of tourniquets in more severe injuries temporary aortic balloon catheter tamponade tranexamic acid (TXA) surgical haemorrhage control

»selective embolisation of bleeding vessels and organs

»stent grafting

»temporary intravascular shunts (3)

Early haemorrhage control

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Data published in the period between 1 January 1960 and 31 July 2013

(7)

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The common international protocol ATLS (Advanced Trauma Life Support)

» ABCDE

- A - airway maintanence,

- B - breathing and ventilation,

- C - circulation and hemorrhage control,

- D - disability-Neuro,

- E - exposure/environment control

(8)

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2L of crystalloidpacked red blood cells (PRBC) and fresh frozen

plasma (FFP) 1:1and platelets 1:1:1haemoglobin and/or haematocrit base deficits and lactate levels trauma-induced coagulopathy may be present in 25%

of patients crystalloid use is limited »transfusion of platelets to keep count above 100,000/ mL

(8)

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internal rotation of the legs stabilisation of pelvic ring injuries the pelvic C-clamp

(8)http://khourychiropractic.com.au/uncategorized/hips-dont-lie/

https://www.researchgate.net/figure/7386583_fig2_FIG-2-A-Circumferential-pelvic-

antishock-sheeting-is-applied-in-this-example-patient

https://www.depuysynthes.com/hcp/trauma/products/qs/pelvic-c-clamp-1

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pneumatic pressure using Military antishock trousers (MAST)

http://www.fire-city.kurume.fukuoka.jp/fire/dousuru/kyukyutai1.html

vacuum mattress

http://unikon.lv/lv/produkti/vakuuma_matracis_res_q_matt(8)

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Bleeding stoppage techniques during operation

Electric cauterySuture ligationSelective embolizationSterile metallic or titanium thumbtacks,

occluder pin Pelvic packing (roller gauze)

http://www.scielo.mec.pt/scielo.php?

script=sci_arttext&pid=S1646-69182013000300004

http://hemoccluderpin.com/hemorrhage-occluder-pin/

http://img.diytrade.com/smimg/

2177743/40309416-4021433-0/

Electrocautery_Pen/8a25.jpg

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Male, 57 years oldAdenocarcinoma of the rectum the bleeding site was identified on the anterior surface

of the sacrum pressed with finger Electric cautery, suture ligation Hemostatic agentsLeft three large laparotomy laps packed in pelvis

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4h »2000ml Er concentrate

»500ml plasma

»6000ml crystalloids and colloids

Transferred to ICU48h removed the packs ICU discharged 7 days after the second

operation

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Female, 46 years old the presacral venous plexus was bleeding profuselydiathermy and compression packing ligated the right internal iliac artery, the left internal

iliac artery, the left internal iliac vein5 sterilized thumbtacks at the bleeding point around

the sacral plexus region along with compression packing with gauges

packed the pelvic cavity with roller gauges bounded together in knots and brought out to the skin

was discharged successfully

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Conventional hemostatic procedures, such as tamponing, suturing, and cauterization, sometimes do not resolve but just perpetuate the hemorrhage.

Traditional methods for stopping bleeding include pelvic packing and the use of sterile metallic or titanium thumbtacks. Packing has the disadvantage of reoperation for removing the packs and risk of re-bleeding.

Situation in Latvia?

Discussion

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Thank you!

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1. Advanced Trauma Life Support Student Course Manual 8th edition, 2008

2. Advanced Trauma Life Support Student Course Manual 9th edition, 2012

3. Damage control resuscitation: lessons learnedM. Giannoudi, P. Harwood, 2016

4. Damage Control Management in the Polytrauma Patient. Hans-Christoph Pape, Andrew B. Peitzman, C. William Schwab, Peter V. Giannoudis

5. Атлас анатомии человека. В 4 томах. Том 3. ст. 149-150.Р.Д. Синельников, Я.Р. Синельников, А.Я. Синельников. Москва, Новая волна, издатель Умеренков, 2012

6. Anatomy of the Sacral Venous Plexus, Robert M. Zeitt and Constantin Cop, 1982

7. Surgical management of presacral bleeding. V Celentano, JR Ausobsky, P Vowden Bradford Teaching Hospitals NHS Foundation Trust, UK, 2014

8. Emergency Treatment for Clinically Unstable Patients with Pelvic Fracture and Haemorrhage, Roman Pavi and Petra Margeti, 2012

References